Approach to Improving Safety

Target Audience

Perspective

December 1 marks the tenth anniversary of the Institute of Medicine (IOM) report To Err Is Human, the blockbuster that launched the modern patient safety movement.(1) The anniversary provides an opportunity to reflect on the forces that have promoted safety efforts over the past decade. They include a more robust accreditation environment, increased reporting of adverse events to state and other regulatory bodies, growing implementation of information technology, skill-building support by organizations such as Institute for Healthcare Improvement, and a maturing research field supported by AHRQ and others.

But, by serving as an essential catalyst for all of these forces, media coverage of patient safety might well be the most crucial element of all.

It is human nature to avoid confronting existential but ill-defined threats, whether from terrorism, global warming, financial meltdowns, or medical mistakes. Before late 1999, while many people understood that health care could cause harm, this concern was too inchoate to generate real change in the culture and structure of health care. Whereas these other threats sometimes force their way into public consciousness through a single cataclysm (9/11, a 500-point drop in the Dow), medical errors occur one at a time, generally hidden from public view. The problem of patient safety needed to be brought into sharper focus if it was going to receive the attention and resources required for change. This focus was provided in large measure by the media.

Even before the IOM report, several errors generated widespread media coverage and began to till the soil for a national patient safety movement. Perhaps the two biggest were those leading to the deaths of Libby Zion in New York Hospital in 1984 and Boston Globe health columnist Betsy Lehman at Dana-Farber Cancer Institute in 1995.(2,3) Both these cases created short spasms of focus, but neither generated enough pressure to "tip" the issue of patient safety. It required the IOM report—particularly its made-for-TV analogy that the deaths from medical mistakes in the United States were the equivalent of a jumbo jet crashing every day—to ultimately spark the safety movement.(1,4)

These examples—the Zion and Lehman cases and the IOM report—illustrate two general categories of media coverage of patient safety. The first, typified by To Err Is Human, involves broad, analytical pieces that tackle the general problem of safety (or large safety issues such as medication errors or hospital-acquired infections), providing data and analysis that help readers or viewers understand the nature of the problem and potential solutions. Although such pieces often utilize actual cases to bring the statistics to life, these cases are exemplars, not central.

On the other hand, we have media coverage of individual cases (Table), illustrated most recently by the stories that followed Dennis Quaid's twins' massive heparin overdose at Cedars-Sinai Medical Center in Los Angeles in 2007.(5) Such cases have natural drama and often succeed in raising the public angst level. When we are lucky, breathless coverage of a single case later leads to more thoughtful analyses of the safety hazards it illustrates, accompanied by discussions of potential solutions.

Obviously, only a tiny fraction of errors make headlines, which raises an intriguing question: what makes some medical errors newsworthy and others not (6)? It cannot just be frequency: the heparin dosing error experienced by the Quaid twins has happened hundreds of times, and millions of medication errors occur every year. It is not even a matter of severity, since fatal errors occur with alarming frequency. Looking back at the big, mediagenic errors over the past 25 years (Table), a striking pattern emerges: most took place in large academic medical centers in the Northeast corridor, and many involve celebrities. It goes without saying that this is decidedly unfair, both to the hospital and providers who have the misfortune to find themselves in the klieg lights, and to the thousands of patients whose harm went unchronicled.

More importantly, the arbitrariness of the media coverage may create a skewed public perception regarding risks. There is no evidence that the hospitals that hosted these errors are particularly unsafe. In fact, many of them show up on various "top hospitals" lists, which may be why celebrities frequent them. And the focus on teaching hospitals creates disproportionate public anxiety about being cared for by residents—there is no evidence that teaching hospitals are less safe than hospitals without trainees. Yes, residents need more supervision and more sleep (7), but it seems unlikely that a patient being cared for by residents at Harvard or UCSF at 2:00 AM is in more peril than a similar patient in a community hospital whose attending physician is asleep at home. It is also likely that these academic institutions are more prone to provide team-based care and to openly discuss errors (at M&M and other conferences), all of which increase the chances that errors will see the light of day, and ultimately the front page of the local paper.

While caregivers at these spotlighted hospitals can be forgiven for being annoyed at the unwelcome media scrutiny, it may well be that such hospitals are less risky for having been in the media's cross hairs. Johns Hopkins created a world-class safety program, driven in part by the media coverage over the death of a young child, Josie King.(8) On this site, leaders from Dana-Farber and Duke described the catastrophic effects of their highly public errors on their institutions, effects that led to changes that markedly improved safety for subsequent patients.(9,10)

What do we need from reporters who cover the medical errors beat? As discussed in my interview with Pulitzer Prize–winning health care reporter Charlie Ornstein that accompanies this Perspective, reporters need to know enough about error science that they appreciate the importance of searching for systems factors, without immediately zeroing in on more dramatic and obvious sharp-end errors. They need to get the facts right. And, while raising the appropriate concerns, they need to avoid sensationalism and place the error, or the topic, in broader context. When they do these things, they are providing a unique and critical service to patients and caregivers.

While providers and health care organizations will understandably feel singled out, perhaps unfairly, when they are the subject of a media report (and such reports these days are as likely to be on a blog or YouTube video as an article in the local newspaper), it is important that we keep our perspective. Just as the physician signing the surgical site, the nurse cleaning her hands, the quality manager developing a systems fix for an unsafe condition, and the informaticist implementing computerized order entry are contributing to patient safety, so too is the reporter who writes an honest, thoughtful analysis of a safety issue or describes a terrible medical mistake. In the end, I completely agree with the health care journalist Michael Millenson, who observed (11):

It was the mirror held up to the profession by news media coverage that finally penetrated the self-protective shell of rationalizations, subverted the old paradigm, and prompted the current effort to develop a systems oriented patient safety approach... In the case of medical errors, public scandal and the concomitant fear of public shaming finally broke through professional complacency.

Robert M. Wachter, MDProfessor and Associate Chairman, Department of Medicine
University of California, San Francisco
Editor, AHRQ WebM&M and AHRQ PSNet

New focus on medication errors, role of ambiguity in prescriptions, and possible role of computerized prescribing and decision support

Willie King, a 51-year-old diabetic, has the wrong leg amputated

University Community Hospital, Tampa, FL

1995

New focus on wrong-site surgery, ultimately leading to The Joint Commission's Universal Protocol to prevent these errors

Two healthy young volunteers (Jesse Gelsinger and Ellen Roche) die while participating in research studies

University of Pennsylvania (JG); Johns Hopkins (ER)

1999 and 2001

New focus on protecting research subjects from harm

18-month-old Josie King dies of dehydration

Johns Hopkins Hospital

2001

Josie's parents form an alliance with Johns Hopkins' leadership (leading to the Josie King Foundation and catalyzing Hopkins' safety initiatives), demonstrating the power of institution–patient collaboration

Jesica Santillan, a 17-year-old girl from Mexico, dies after receiving a heart-lung transplant of the wrong blood type

Duke University Medical Center

2003

New focus on errors in transplantation, and on enforcing strict, high-reliability protocols for communication of crucial data

The twin children of actor Dennis Quaid nearly die after receiving a massive heparin overdose